To kick us off, it's my pleasure to introduce Jill Olmstead. Jill is an adult nurse practitioner at Providence St. Joseph Health in Fullerton, California. She's practiced as an NP for over 15 years, specializing in gastroenterology. Her practice includes evaluating and managing new patient consultations, follow-up visits, and diagnostic flexible sigmoidoscopies. She's a credentialed certified coder, a clinical documentation improvement specialist, and a risk adjustment coder. We can all certainly learn something from Jill. Jill is a fellow in the American Association of Nurse Practitioners and currently serves on ASGE's reimbursement committee. Jill, the audience is yours. Thank you, Sarah. So it's an honor to be invited back and being part of this program. What I wanted to do today is go over with you the fundamentals of the gastroenterology consultation note. I wanted to let you know that I have no disclosures. And the key of the presentation today that I'll be going over is the key elements of the consultation note and going over highlights of coding guidelines. So the first polling question is, what are the three components for a consultation note? So is it one, referral, render, and report? Is it two, referral, records, and follow-up? Three, report, records, and referral? And four, report, records, and follow-up? These are the key guidelines that are required for the AMA CPT code for the consultation code set series. Great. So the correct answer is number one, referral, render, and report. And these are specific guidelines that you'll see in the 2022 AMA CPT code book for the consultation codes 99241 to 99245. Okay, so next, as we kick off, so question two, does Medicare pay for outpatient codes 99241 to 99245? So actually, the answer to the question is no. So this is a great presentation to be providing to you early this morning. So Medicare stated it's approximately 10 years ago. They do not cover consultation codes. And their decision was that they were not able to audit it correctly to know if this code set series, they were actually being coded correctly. So now Medicare will cover new patient visits or established patients visits. But if you're seeing a Medicare patient in your office, then you need to be billing the new patient visit if this is new to your practice. These arrows are so small. So the objections this morning, we're going to define the elements of utilizing the consultation codes. Look at the E&M coding guidelines, and there are three sets of coding guidelines. There's 1995, 1997, and 2021. Discuss the importance of capturing clinical concepts and review some key concepts for correct coding. So the three elements of your evaluation and management guidelines are your history and physical, physical exam, and medical decision making. And what's interesting is, I think to myself, how long will we be educating on 1995 and 1997 guidelines? Because since last year during the pandemic, the 2021 guidelines came into effect beginning of last year. And actually CMS and AMA said, OK, we're going to actually roll those out the end of 2020. So now the 2021 guidelines have been implemented because it's supposed to reduce less administrative burden for us as providers to be able to document the information that we need for our patients. So the history of presenting illness is going to include your history that you're taking for your patients, your review of systems, your past medical history, your family medical history, and your social history. And now fast forward with the 2021 guidelines, that information is not dictated by bullet points or exactly how many different information pieces that we need from our patients. What's interesting, though, is that you'll find with Dr. Vicari's presentation is that those items, we really need that history for our GI consultation. So think about your practice. Even though we don't need to have all that information for a new patient visit because of the 2021 guidelines, for our GI consultation notes and for any newer experienced advanced practice providers, it behooves us to still gather all that information because it's important for us to be able to take care of our patients and come up with an accurate differential diagnosis. We have the physical exam section and then the medical decision making. Now, the medical decision making section of our note includes the number of problems, the complexity of the problems, the amount of data that we review, and the risk and complications or mortality and that table of risks for our patients. So now the 2021 guidelines are driving that medical decision making is the most important aspect of caring for our patient. But how do we get to that medical decision making? Even from a newer experienced clinician, we want the information that we gather from our history and from our physical examination. So just to go over the coding guidelines, new and consultation codes and established patient visits. So that new patient visit for us to be able to code and the 99202 Series 05, no services are required to be rendered within three year time period. And some organizations will actually have billing edits in place so they can actually determine whether a new patient has been provided by your department and they'll hold that visit and then they'll flip it over to an established patient visit. Now the 99241 to 045 Series, these consultation codes, again, we established are not covered by Medicare, but there are some pairs that will cover it. And there is a small amount of reimbursement that's greater than the new patient visits. So the take home message for this is go back to your institutions and find out, what do you want me to do? Do you want me to code the consultation codes or are you going to change them if that payer does not happen to pay for them? So our institution said, we want you to still build consultation codes. We'll take care of it on the back end, so to speak. So we still have payers in Southern California that will pay for this code set series. Again, just to reiterate, it's that code set series that you need to have those three elements. But even when we're providing good care for our patients, we still want to have those three elements for our consultation notes, which is your history, your physical examination, your medical decision-making, and also time-based coding you can use now with 2021 guidelines, which is the actual time that is spent with your patient and reviewing your records even before the patient walks in the room, as long as it is during that date that you're seeing that patient. So this is an overview of the consultation code series and the new patient visits. So under history, your physical exam, your medical decision-making, and I've also given you for your reference the amounts of time that you need to document if you're using time-based coding. You can choose one or the other. You're going to use either the guidelines, the 95, 97, or 21 guidelines, or you'll use time-based coding. So the consultation services requirements, like that first polling question, you need a referral. So someone needs to refer that patient to you. If a patient comes in on their own and they're self-referred, then that would automatically be a new patient visit. But sometimes what you'll find out with the history is that the primary care doctor really did refer them. Patients will say, oh, no, I decided to come in on my own, but the referring physician may have been six months ago and that referral was in. So you want to document that information. Rendering, so you're providing your own opinion, and then you're sending a report to the referring physician. Sometimes I'll see new patients that have self-referred, they'll come in on their own, and they haven't established with a primary care physician yet. So I would not be able to use a consultation code series. So this is a GI consultation case study that I want to go over with you. So it's a 45-year-old male that's referred by an outside physician for a GI consultation for a change in bowel pattern. And here are the bulleted items, your past medical history, your family history, your social, so physical examination. On another slide, you'll see that it's bulleted for the 1995 guidelines. Your differential diagnosis. So that's part of your medical decision-making. If you have a patient that comes in with change in bowel habits, acute diarrhea, unknown etiology, possible infectious or inflammatory process, and you want to list out what are the different possibilities that you're thinking for this patient that you're going to start working them up. And then your medical plan. This is the cognitive effort that you're putting into deciding how you're going to care for your patient. And this effort is what determines your medical necessity and which then will allow you to build at that higher level, either a moderate or high-level complexity. So your history of presenting illness, you're going to have bullet points from this. You have your duration of frequency and timing. And again, Dr. Bakari will be doing an excellent job going over the elements of a note. So I'm going to go through this slide. And then here's an example of a detailed physical examination. Think of those two 1995 guidelines, you want a two to seven body organs. But again, if you're providing a consultation, you want to have a complete physical examination, but also that's pertinent to your patient that's in front of you. What is the information that you need to gather that's appropriate for the patient that you're seeing? And then medical decision-making, it's going to be your management. If it's a new problem, that's going to be at a higher level. If it's detailed workup, so you're ordering complete blood work. This patient hasn't been seen or cared by anyone over several years. If this differential diagnosis start off with acute versus chronic diarrhea, you're looking at stool studies. You want to rule out an inflammatory process. You're documenting that you're going to order a Calprotectin to make sure there's no inflammatory process versus functional. And then stool studies, including C. difficile and Giardia. So someone that comes behind you that's reading your note is going to know your plan and be able to follow it. So this is also a communication tool, not only for the referring physician, but for your colleagues that may be following after this patient if you're not there. These are the elements of the medical decision-making that we discussed. You've got your type. You have the low complexity, moderate, and high complexity. And what's interesting out of this table of risks, you do need two out of the three to meet to then be able to say what that medical decision-making is for your patient. Here's an example of ICD-10 and CPT coding visit that you'll have some additional information later in the course. So the case study that I reviewed with you, if you use the 1995 and 1997 guidelines, history was identified as a detailed exam. Your physical exam is detailed and the medical decision-making is moderate. Under the guidelines, using 2021 guidelines, now you have different terminology. You've performed a medically appropriate physical exam. Your physical examination was medically pertinent for that chief complaint, and then your medical decision-making is moderate, and you were able to build the 99203. Now, with the consultation codes, you need all three of these elements to meet, but for the 2021 guidelines, you need two out of the three to meet. So ICD-10 coding is a diagnostic coding for your visits. You want to be able to code the diagnoses that patients are presenting to you. If your patient presents with GI symptomatology, but they have other comorbid conditions, then that education piece is that you want to also code that ICD-10 code that's going to impact your care. So if you're seeing a patient who's at 78, they're having rectal bleeding, but they also have congestive heart failure, their EF is 50%, they have paroxysmal atrial fibrillation, they're on anticoagulant therapy. This information is going to go into your medical decision-making, and this also builds a case that this patient is sicker, and I need to spend more time with this patient and put more cognitive thought and recommendations into this patient's care. Now I wanted to provide some additional information when it comes to patient communication. And I think from an experienced GIAPP over the years, our patients come in and they save up a lot of information for us, and they want to give us all this information at once, and I even had a patient yesterday, she said, I don't know what you're going to need for me, but I'm just going to give it all to you. So as you learn, you become very systematic. You start literally from the head and work your way down. You refocus patients, you reframe it, what is the most important problem that you want to talk about today? I had a patient the other day, and she said, well, I want to talk about all of them. So think about when you're working with your patients and providing communication, you want to be uncomplicated. You want to be specific. I had a patient the other day that I thought I was being so uncomplicated, and I finished my thought process with her and reviewed our management plan and had a repeat back. And I said, did you understand everything I said? Do you have any other questions? She said, no, I didn't understand anything. Could you repeat it again? So we have to just be cognizant of where that patient is at that time, especially with other competing anxieties that patients come in, whether they're relocating, whether they're moving, their pet just recently passed away, elderly parents. Patients bring in so much anxiety and stress with us, which is then a driver a lot of times in those GI symptoms. So be uncomplicated, be specific, use some repetition, repeat phrases over again, minimize jargon. And what I like to do with my patient is I'll summarize what I've heard from them. And I'll say, OK, let me repeat back to you and see if what I've heard you say is correct and make sure I've heard everything. Because that's going to be valuable for you if that patient comes back in and follow up and they have a new complaint. And it helps you level set and say, well, did you have any symptoms last month when we talked? Oh, no, no, this is new. Or, oh, yeah, I did have it back then. So again, the fundamentals of this GI consultation is that it is a roadmap for you because you're not going to just see that patient once, they're going to be back to you. So you're building this case, building the story so you can provide this care for your patient. So one of those practice pearls is when you're seeing outside patients, get as much data as possible, especially endoscopy reports. Previous visits, I had a patient last week. She would just relocated from Florida and literally she had just landed one week ago and I was having to pick up that entire GI workup, that patient that had established in Florida. Communicate with your patients what you found and what the next steps are. Document the relevant data to support your medical decision making and then communicate with that referring provider and your referrals. We actually have internal chat systems with our organization. So if something urgent has come up or if I know a patient needs urgent endoscopy and I'm coordinating within the next 24 hours, then we can actually communicate that within our EMR system to let our referring physicians know because they want to also know that we're providing good service and that we're caring for their patients. Stay up to date, follow the coding guidelines and I have a link here of CMS's evaluation of management services, which will give a great overview of your new patient and your established patient visits. Thank you very much for your time and enjoy the rest of your conference.

gastroenterology consultation note

coding guidelines

evaluation and management guidelines

time-based coding

patient communication